Trends in workers' compensation funding for prosthetics

Like all other funding sources in this economy, workers’ compensation carriers have begun to focus more on cost containment. Unlike an amputation due to vascular disease, cancer, or congenitaldefect, injured workers who suffer amputation can hold another party liable. There was a time when obtaining authorization for a prosthesis through a workers’ compensation carrier was a slam-dunk. With a prescription and medical documentation, authorization was granted. Times have certainly changed.

The Squeaky Wheel

An injured worker may be entitled to medical care, but it’s not a bad idea to keep the following guidelines in mind. Sometimes it’s a fine balance between self-advocacy and creating animosity with the carrier.

• Be clear about goals, needs, and expectations when talking to adjusters and registered nurse (RN) case managers.
• Try to obtain approval & denials for care in writing.
• Contact adjusters and registered nurse (RN) case managers regularly with progress updates.
• When additional care is needed, contact the adjuster and/or registered nurse (RN) case manager as soon as possible.
• If something is unclear, require clarification at the time.
• Remember that the use of threatening language and/or tone can have long term effects.
• Keep in mind that once an attorney is brought into the picture, the relationship with the carrier can change and direct contact between the injured worker and carrier may not be allowed.
• Explore all options in problem solving and conflict resolution. If conflicts cannot be resolved, explore the option of changing adjusters or case managers.
• Be responsible about attending medical appointments.
• Do not underplay or exaggerate symptoms.
• If considering settlement, request for a formal life cost projection to be performed. This can help ensure that the injured worker will be reimbursed adequately for possible future medical care.
• Be persistent in achieving positive goals, yet flexible in how these goals can be achieved.

Third Party Administrators (TPA)

Workers’ compensation carriers and self insured companies are relying more now on third party administrators (TPA) to handle medical claims. A TPA can either facilitate a smooth process, or unnecessarily complicate it.

• Major Pro

One entity handles various aspects of the medical claim, including claims processing, appointment transportation, delivery of medical devices, and even translations services. All activity in the claim is contained in one system, though many medical providers may be involved.

• Major Con

There may be a lack of communication among medical providers, the carrier’s adjuster, and RN case manager. The carrier generally contacts the TPA directly. The TPA then locates one or more medical providers within the TPA network. The medical provider(s) evaluates the patient and provides the TPA with documentation and cost. The TPA takes this costing information, and then adds its own cost for processing the claim and this information is submitted to the carrier. Many times, multiple vendors are asked to provide a quote to the TPA. Such competitive bidding practices may delay the authorization process and, ultimately, could delay care.

Prescriptions

Injured workers usually expect that a prescription from a physician will be required for an initialprosthesis. One aspect of cost containment requires the carrier to ensure that additional care is medically necessary. Carriers are relying now less on prosthetic providers for this medical necessity documentation and more on physicians. It’s very common for prescriptions to be required for even relatively minor component replacement, such as silicone liners for lower extremity prosthetic devices. The downside of this requirement is:

• Physicians often rely on the prosthetist to determine what requires replacement and why. How effective, then, is the new prescription requirement at ensuring medical necessity?
• Obtaining this type of medical documentation can delay care.

Long Term Cost

Generally, the healthcare system tends to narrowly view the necessity of prosthetic devices, focusing on the immediate cost of the device. However, providing a lower-functioning prosthesisnow, or delaying care due to a lengthy authorization process, could add more dollars to the claim in the future. There are many prosthetic systems that reduce stress on the amputee and promote healthier residuallimb tissue. These systems, such as the VASS system (Vacuum Assisted SocketSystem) and the C-Leg, are proven to increase function for many amputees. Unfortunately, these systems are higher in cost than other prosthetic designs. What is the cost of inactivity? What is the cost of skin breakdown on the residuallimb? As far as long term cost, permanent disability andrevision surgeries are much more expensive for the carrier.

Distrust

There are many prosthetic providers who abuse the workers’ compensation system by providing high-cost prosthetic care without providing the necessary training and follow-up. When this happens, the myoelectric arm or microprocessor leg could end up sitting in a closet. A prosthetic provider who wants to appropriately utilize funds from the carrier will:

• Thoroughly evaluate the amputee. Not everyone is a candidate for a microprocessor leg ormyoelectric arm. The prosthetic design and components should be functionally appropriate for the injured worker.
• Provide adequate training. Initial prosthetic training should occur during the fitting process, and during follow up appointments. Intensive occupational therapy from the licensed occupational therapist can help ensure that the injured worker is using the prosthesis to its full potential. Communication between the therapist and prosthetist is crucial throughout the rehabilitation process.
• Attempt adequate prosthetic adjustment prior to requesting replacement.
• Schedule frequent follow up appointments with the injured worker, to ensure the prosthesiscontinues to fit well and function properly.
• Report progress and prosthetic outcomes to the carrier.
• Attempt to remain neutral during any conflicts between the injured worker and the carrier.
• Honor warranties when valid.

As the healthcare system continues to evolve, injured workers and prosthetic providers will clearly need to adapt to these changes. Insurance carriers also should look at the ‘big picture’ when it comes to providing adequate care. Saving a buck now could really cost them later.